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Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus
Emily G McDonald1, Gloria Aggrey2, Abdullah Tarik Aslan3
1Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada.
Insights
Oral transitional therapy is as effective as intravenous-only therapy for treating infective endocarditis (IE). This finding provides a key recommendation for managing bacterial IE, guiding clinical practice and improving patient outcomes.
Area of Science:
- Cardiology
- Infectious Diseases
- Clinical Guidelines
Background:
- Practice guidelines often present recommendations where the strength of the recommendation is not aligned with the quality of the evidence.
- A gap exists between evidence quality and recommendation strength in clinical guidelines.
Purpose of the Study:
- To develop a clinical guideline for diagnosing and managing adult bacterial infective endocarditis (IE).
- To address the discrepancy between evidence quality and recommendation strength in IE management.
Main Methods:
- A consensus statement and systematic review using the WikiGuidelines method for collaborative guideline development.
- Crowdsourcing and voting on topics related to adult bacterial IE diagnosis and management.
- Literature searches in PubMed, with evidence reporting based on reproducible, prospective, controlled studies for clear recommendations.
Main Results:
- 51 members from 10 countries reviewed 587 articles, addressing 17 unique questions across diagnosis, IE teams, prophylaxis, and treatment.
- A clear recommendation was established for only one question: oral transitional therapy is as effective as intravenous-only therapy for IE treatment, based on 3 randomized clinical trials.
- Clinical reviews were generated for the remaining questions due to insufficient high-quality evidence.
Conclusions:
- The WikiGuideline method was applied to develop a consensus statement for adult bacterial IE.
- Oral transitional therapy is demonstrated to be as effective as intravenous-only therapy for IE treatment.
- Further research and ongoing clinical trials are necessary to inform other aspects of IE practice.
Importance:
Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence.
Objective:
To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength.
Evidence Review:
This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches.
Findings:
A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions.
Conclusions And Relevance:
In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.
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